John Piacentini on Treating Tics Associated With Tourette Syndrome

A comprehensive behavioral therapy is more effective than basic supportive therapy and education in helping children with Tourette syndrome manage their tics, according to a study funded by the National Institute of Mental Health (NIMH). The study was published May 19, 2010, in a special issue of the Journal of the American Medication Association dedicated to mental health.

"People with Tourette syndrome experience considerable impairment and social isolation, and effective treatments are limited," said NIMH Director Thomas R. Insel, M.D. "This study makes a strong case for a specialized behavioral therapy, either as a stand-alone treatment or as an adjunct to medication."

Tourette syndrome is a chronic neurological disorder that is associated with motor or vocal tics that can be embarrassing and disruptive. It is commonly treated with antipsychotic medication such as haloperidol or risperidone. But these medications often are unable to eliminate tics entirely. They also are associated with troubling side effects such as weight gain and sedation. Few studies have examined the effectiveness of behavioral interventions.

John Piacentini, Ph.D., of the University of California Los Angeles, and colleagues tested the effectiveness of a Comprehensive Behavioral Intervention for Tics (CBIT), a therapy based on habit reversal training that includes two concepts—tic-awareness and competing-response training. Tic-awareness training teaches the child how to self-monitor for early signs that a tic is about to occur. Competing-response training teaches the child how to engage in a voluntary behavior designed to be physically incompatible with the impending tic, thereby disrupting the cycle and decreasing the tic. For example, a child with vocal tics who blurts out words or sounds inappropriately may be taught slow rhythmic breathing techniques to manage the urge to vocalize.

CBIT includes parent training as well. Parents in the study were taught how to manage their own reactions to their children's tics, and how to best encourage and praise their children for practicing the behavioral intervention techniques they were learning.

"CBIT emphasizes the development of skills that foster autonomy and empowerment, allowing for patients and their families to take an active role in treatment," said Dr. Piacentini.

The researchers randomized 126 children ages 9-17 at several sites to either CBIT or a control treatment that included supportive therapy and basic education about the condition. Each group received eight sessions over a 10-week period. Those who responded to therapy received monthly booster sessions for three months, and were assessed three months and six months after the 10-week acute treatment ended.

About 52.5 percent of the children who received CBIT showed significant symptom improvement compared to 18.5 percent receiving the control treatment. The benefits of CBIT also appeared to endure over time—87 percent of CBIT responders who were reassessed six months after the end of the 10-week trial continued to benefit.

"The response to CBIT is comparable to results of trials with antipsychotic medications for Tourette syndrome," said Dr. Piacentini.

In addition, few children dropped out of the study, suggesting that the intervention was well-received and tolerated by both the children and parents. Moreover, the researchers note that 38 percent of children in the study were already taking medication for their disorder when they entered the study and were allowed to remain on the medication. Many also had co-existing disorders. Both these conditions mimic real-world situations, making the results more relevant to clinical populations.

The authors note that although CBIT helped many children, not all children in the study benefited from the treatment. They suggest that future analyses may provide guidance on who is most likely to respond to the therapy, allowing for more personalization of treatment. "We've shown that it works about as well as the standard medications for tics but without the negative side effects," concluded Dr. Piacentini. "Knowing that CBIT is effective for many patients with Tourette syndrome adds to the available treatment options for this disorder."